The Safety and Efficacy of the Early Use of Sacubitril/Valsartan After Acute Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials.

Acute myocardial infarction (AMI) is a significant global cause of mortality, necessitating the exploration of innovative treatments against the condition. Angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan have demonstrated promise in managing acute heart failure (HF). However, despite favorable evidence from clinical trials for the use of sacubitril/valsartan in AMI, its overall efficacy remains a subject of debate. Hence, we conducted this review and meta-analysis, by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and aligned with European Society of Cardiology recommendations, to compare sacubitril/valsartan with traditional ACEI/ARB treatments for AMI. We employed Review Manager 5.4 for statistical analysis, the Risk of Bias Tool 2.0 was utilized for quality assessment, and publication bias was assessed using a funnel plot. A p-value <0.05 was considered statistically significant. Eight randomized controlled trials (RCTs) were included in this meta-analysis. Our findings revealed that participants treated with sacubitril experienced significantly improved outcomes in terms of HF (OR=0.79; 95% CI: 0.66-0.95; p=0.01; I2=23%), N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (MD = -1.58; 95% CI: -1.78 to -1.37, p<0.00001; I2=97%), and major adverse cardiovascular events (MACE) (OR=0.84; 95% CI: 0.72-0.99; p=0.03; I2=44%). However, left ventricular ejection fraction (LVEF) (MD=3.68; 95% CI: 3.35-4.01, p<0.00001; I2=71%) showed greater improvement in the control group compared to the experimental group. Our meta-analysis suggests that sacubitril offers a favorable balance between safety and effectiveness. Sacubitril significantly improved outcomes in terms of HF, MACE, and NT-proBNP levels when compared to the control group. However, improvement in LVEF was notably higher in the control group over the sacubitril/valsartan group.

Congenital Immature Grade ΙΙΙ Teratoma of the Neck: A Case Report.

Teratoma is a rare type of germ cell tumor that consists of structures derived from all three germ layers of the embryo with varying proportions. While most of these are benign, some can turn malignant. The most common location of teratomas is the sacrococcygeal region, while their occurrence in the neck region is very rare. Broadly classified, immature teratomas contain poorly differentiated tissues, while mature ones have well-differentiated tissues. Here, the authors present a case of a 12-month-old child who presented with a huge neck mass. Radiological imaging studies were performed. Under a multidisciplinary team approach, the child was treated successfully with surgical excision. Histopathology revealed the mass to be an immature teratoma of grade III. Postoperatively, no recurrence has been noted.

Common femoral vein thrombosis caused by a metal-on-metal hip arthroplasty-related pseudotumor.

We present a case of a pseudotumor causing a deep femoral vein thrombosis 16 months after undergoing a metal-on-metal total hip arthroplasty. There is increasing concern over the effect of metal ions that are produced by wear in metal-on-metal hip arthroplasty systems. Recently, a number of articles have reported the development of an inflammatory pseudotumor causing a number of different problems early on in the lifespan of the implant necessitating revision surgery. This case reports the first presentation of a pseudotumor causing a serious venous thrombosis due to pressure effect and indicates further possible evidence for caution when considering metal-on-metal bearing hip arthroplasty.

Comparison of Miniplate and K-wire in the Treatment of Metacarpal and Phalangeal Fractures.

Introduction Metacarpal and phalangeal fractures are common upper limb fractures due to direct blows, axial loading, and torsional loading injuries. The universal goal in treating all fractures for the patient to achieve normal motion, but the ideal technique for stabilization is still debated. For internal fixation, Kirschner wires (K-wires) or miniplates can be used, and each carries certain advantages. No previous study has compared K-wire use to miniplate use in treating metacarpal and phalangeal fractures. Therefore, we conducted this randomized control trial to evaluate the outcomes of K-wire and miniplate use in treating metacarpal and phalangeal fractures. Materials and methods This randomized controlled trial was conducted in the Department of Orthopaedic Surgery, Bahawal Victoria Hospital, from February 2017 to February 2018. Seventy-five patients were included in this study and randomly assigned into two groups. One group was treated with K-wire fixation, and the other group was treated with miniplate fixation. We assessed total active motion (TAM), range of motion (ROM), duration of injury, and complication rate. Data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (Armonk, NY: IBM Corp). P values ≤ 0.05 were considered significant. Results Mean surgical time, pain scale, and time of union of K-wire treated patients was 38.63±3.64 minutes, 4.17±1.11, and 12.95±3.38 weeks, respectively. The success of the union was noted in 38 K-wire patients (95%). Total active ROM was greater in miniplate fixation patients compared with K-wire treated patients, but this difference was statistically significant. Similarly, TAM was also greater in the miniplate fixation patients compared to the K-wire treated patients, but this difference was also not statistically significant. Conclusion Both K-wire fixation and miniplate fixation are equally effective in terms of TAM, ROM, and complications when used to treat metacarpal and phalangeal fractures.

An Ectopic ACTH Secreting Metastatic Parotid Tumour.

A 60-year old woman presented with features of Cushing's syndrome (CS) secondary to an ectopic adrenocorticotropic hormone (ACTH) secreting metastatic parotid tumour 3 years after excision of the original tumour. She subsequently developed fatal intestinal perforation and unfortunately died despite best possible medical measures. Ectopic ACTH secretion accounts for 5-10% of all patients presenting with ACTH dependent hypercortisolism; small cell carcinoma of lung (SCLC) and neuroendocrine tumours (NET) account for the majority of such cases. Although there are 4 previous case reports of ectopic ACTH secreting salivary tumours in literature, to our knowledge this is the first published case report in which the CS developed after 3 years of what was deemed as a successful surgical excision of primary salivary tumour. Our patient initially had nonspecific symptoms which may have contributed to a delay in diagnosis. Perforation of sigmoid colon is a recognised though underdiagnosed complication associated with steroid therapy and hypercortisolism. This case demonstrates the challenges faced in diagnosis as well as management of patients with CS apart from the practical difficulties faced while trying to identify source of ectopic ACTH.

Factors associated with patients in the Scottish Highlands who chose mastectomy when suitable for breast conservation.

BACKGROUND: Despite being suitable for breast conservation surgery (BCS) a proportion of women choose mastectomy. This study aimed to assess the pre-operative pathological and geographic factors associated with choosing mastectomy rather than BCS in a single centre that serves a large geographical area encompassing urban, rural and remote island populations. METHODS: A retrospective analysis of all patients suitable for BCS between January 2011 and December 2013 was undertaken. Pre-operative pathological features were compared using the Pearson chi squared test as was distance to the treatment centre from the patient's home. A questionnaire was sent to all those who chose mastectomy to identify the factors that influenced their decision. RESULTS: A total of 446 patients suitable for BCS were identified of which 46 (11%) chose to undergo mastectomy. Patients choosing mastectomy were more likely to present symptomatically (P=0.009), have tumours larger than 20 mm at diagnostic imaging (P=0.001) and have positive axillary staging (P=0.004). Patients choosing mastectomy were more likely to live remotely (P=0.051). Those patients who chose mastectomy felt this gave a better long-term outcome (18 patients, 44%) and peace of mind (14 patients, 34%). CONCLUSIONS: Adverse pre-operative pathological features were associated with patients choosing mastectomy rather than BCS. There was a trend for patients who chose mastectomy to live remotely from the treatment centre. Patients choosing mastectomy most commonly cited a better long-term outcome and peace of mind as the reason behind their decision. Understanding what influences a patient's surgical choice will allow clinicians and patients to engage in a fully informed pre-operative decision making process.

Risk assessment in acute non-variceal upper GI bleeding: the AIMS65 score in comparison with the Glasgow-Blatchford score in a Scottish population.

INTRODUCTION: The early use of risk stratification scores is recommended for patients presenting with acute non-variceal upper gastrointestinal (GI) bleeds (ANVGIB). AIMS65 is a novel, recently derived scoring system, which has been proposed as an alternative to the more established Glasgow-Blatchford score (GBS). OBJECTIVE: To validate the AIMS65 scoring system in a predominantly Caucasian population from Scotland and compare it with the GBS. DESIGN: Retrospective study of patients presenting to a district general hospital in Scotland with a suspected diagnosis of ANVGIB who underwent inpatient upper GI endoscopy between March 2008 and March 2013. OUTCOMES: The primary outcome measure was 30-day mortality. Secondary outcome measures were requirement for endoscopic intervention, endoscopy refractory bleeding, blood transfusion, rebleeding and admission to high dependency unit (HDU) and intensive care unit (ICU). The area under the receiver operating characteristic (AUROC) curve was calculated for each score. RESULTS: 328 patients were included. Of these 65.9% (n=216) were men and 34.1% (n=112) women. The mean age was 65.2 years and 30-day mortality 5.2%. AIMS65 was superior to the GBS in predicting mortality, with an AUROC of 0.87 versus 0.70 (p<0.05). The GBS was superior for blood transfusion (AUROC 0.84 vs 0.62, p<0.05) and admission to HDU (AUROC 0.73 vs 0.62, p<0.05). There were no significant differences between the scores with respect to requirement for endoscopic intervention, endoscopy refractory bleeding, rebleeding and admission to ICU. CONCLUSIONS: AIMS65 accurately predicted mortality in a Scottish population of patients with ANVGIB. Large prospective studies are now required to establish the exact role of AIMS65 in triaging patients with ANVGIB.

Dual pathology-An unreported case.

INTRODUCTION: Symptomatic biliary disease in children and young adults requiring surgical intervention are uncommon. However even rarer is the occurrence of a spontaneous gallbladder necrosis in a child. We report a case of spontaneous necrosis in a child with no apparent causative factors. CASE: Fit and well 16 year-old boy presented with acute generalized lower abdominal pain. Examination revealed mild epigastric pain with rebound tenderness and guarding of the right iliac fossa. Diagnostic laparoscopy showed a necrotic gallbladder and incidental finding of a Meckel's diverticulum. He had a cholecystectomy and Meckel's diverticulum resection. Patient recovered uneventfully and was discharged home. He was reviewed 2 months later and recovered well with no evidence of any post-operative complication. He was discharged without any further follow up. DISCUSSION: Gall bladder necrosis is a rare cause of an acute abdomen. We present the first reported case of a spontaneous gallbladder necrosis with no apparent cause. Literature review showed various causes of gall bladder necrosis including trauma, acalculous cholecystitis, gallbladder torsion, gangrenous cholecystitis and etc. CONCLUSION: We report a case of spontaneous gallbladder necrosis in a young healthy male with no family history of thrombotic disorders or any history of sepsis, intervention, trauma and no obvious underlying anatomical or histological abnormalities. This is an exceedingly rare pathology and one would be forgiven for not including it on the list of a differential diagnosis in such circumstance. However it is important to send tissue sample to exclude any underlying histological aetiological factors.

Oesophageal GIST-A rare breed case report and review of the literature.

INTRODUCTION: Gastrointestinal stromal tumours (GIST) account for only one percent of all gastrointestinal malignancies. PRESENTATION OF CASE: A 53 year old lady presented to the gastroenterology clinic with iron deficiency anaemia. Oesophagogastroduodenoscopy (OGD) and computed tomography (CT) demonstrated a non-obstructing 7cm submucosal oesophageal lesion. An oesophagectomy was performed and subsequent histology sections showed a well-circumscribed spindle cell tumour without any cellular atypia. Immunohistochemistry on the tumour was negative for S100 and positive for smooth muscle actin and desmin. C-kit (CD117) showed focal positivity in some of the tumour cells and the overall features were of a gastro-intestinal stromal tumour (GIST). The patient has been fully compliant with the follow-up arrangements and is disease-free six years after her original operation. DISCUSSION: GISTs are mesenchymal tumours of the gastrointestinal (GI) tract that express the KIT protein. The incidence rate for GIST is 15 cases to one million in the USA. GISTs in the oesophagus are rare (5%) and their management is surrounded by some debate. Once the diagnosis has been secured the patient should be evaluated for suitability for surgical resection. Optimal surgical therapy should aim to achieve complete resection, if possible, without injury to the pseudocapsule surrounding the tumour. Meticulous atraumatic surgical technique is necessary and preoperative biopsies are best to be avoided as they might propagate seeding. CONCLUSIONS: Oesophagectomy with clear resection margins should be the preferred method for surgical treatment combined with the use of novel TKI strategies.